A Pregnant Pause

As most of us are aware, medical education is a long-term endeavor. Medical schools provide students with the informational foundation and thinking skills necessary to be a doctor. Residency forges the knowledge into a usable skill set that builds the final product: a clinician. Like a hand-thrown pot being placed in the kiln to achieve the final step—that is, hardening with a lustrous glaze—newly graduated medical students take their place in residency programs to gain the experience necessary to practice medicine. It is a system that has worked for generations.

It has worked—but at a price. Many older physicians “put in their dues” at a cost of brutal working hours—often exceeding 120 hours per week—with no patient volume caps, no days off, and absolutely no regard for the resident’s home life or family. In recent years, changes have been made in residency programs to limit the hours worked per week and the number of patients a physician in training is expected to admit and cover; primarily, these changes have been imposed on institutions to address issues of patient safety. It may be time to take a fresh look at residency programs and develop creative work plans that accommodate the changing needs of physicians and twenty-first century medicine.1

What has changed? Everything. The patients changed, the doctors changed, our society changed, and the knowledge base changed; literally, nothing remained static. Increasing demand for patient participation in medical decision-making, increasing requirements for medical documentation, and increasing demand for proof of quality performance while concomitantly paring back the working hours permitted per resident have stressed a rigid system to its breaking point. Creative ideas, such as having residents admit to a single hospital floor, are new innovations to adapt quality teaching to the required 80-hour week.1

Additionally, in the past 25 to 30 years, medicine changed from a “man’s career” to a near gender-neutral profession. In 1970, about 7% of physicians were women. By 1980, women accounted for 11.6% of the workforce, and in 2004, women physicians comprised more than 26% of the total.2 With medical school matriculants numbering women and men at near parity—women have made up 45% to 49% of medical school classes since 1999—it is reasonable to assume that the percentage of women physicians will continue to rise annually.3 This process, the feminization of medicine, has created new needs and demands that have not traditionally been identified.4

As previously noted, medical education and training constitute a long-term process that extends into an individual’s later 20s and 30s. Deferred life issues such as marriage and children can wait only so long, and for women the biological clock imposes an earlier time frame than the one for men. Women often want to start a family before the end of their residency training. The traditional residency system was not designed to support multiple extended absences. In most residency programs—77% of programs in one study—maternity absences are handled by requiring the other residents to pick up the slack, an obviously less than happy arrangement.5,6 In the same survey, 83% of residency programs acknowledged that maternity leave had a significant effect on scheduling, despite the fact that 80% of programs had a maternity policy in place.5

It is time for innovative thinking for residency training. New plans must accommodate system needs as well as individual needs and must retain the teaching function necessary to develop the required clinical skills. This can be done, but it requires planning and flexibility. Most residency programs have a maternity policy.5 This policy defines the length of time allotted for maternity leave—free leave, or time off with no make-up requirement. Some programs, such as the one at the University of California at San Francisco, have incorporated a flexible option to accommodate longer absences using flexible make-up time.7

As early as 1989 the National Health Service in the United Kingdom proposed a part-time option in residency training to encourage women physicians to pursue careers in hospital medicine.8 In response to increasing numbers of women physicians, flexible part-time specialty training programs are now generally available in the United Kingdom.9

Developing a functional part-time residency option requires planning ahead and setting aside several residency slots to be paired as half-time equivalents. Training programs want upfront information; they want to have some idea of how many residents plan to start a family during residency years so that they can anticipate the numbers needed for clinical coverage. One would hope that open communication on this issue would not imply discrimination in hiring and that the information would be used to estimate the hiring needs of the program and to accommodate shared practices.

Obviously, some residents who anticipate using the part-time option may later choose not to have children at that time, while others who did not plan to do so may become pregnant. Because of this variability and the inherent concern of discrimination on the basis of the request, it is preferable for residency programs to build in half-time residency slots based on the need experienced in prior years. Once this program is viewed as a standard option, women with young children—or those who anticipate pregnancy during residency—may well request one of the part-time slots to accommodate their needs.

Flexible—part-time—residency programs have the downside of extending the length of training. Although most residents do not relish the idea of a longer residency, for individuals with family commitments this is a welcome option. The extended residency is a benefit if it allows completion of a training program that might otherwise be impossible.

Of women physicians with children in 1988, 22% had a child before finishing residency, and 54% had at least one child by the time they had completed a fellowship.10 I would guess that those percentages are significantly higher with newer data. All residency programs with young women physicians should anticipate pregnancy-leave time. Without a clear plan to cover the clinical workload during these absences, one can predict anger and resentment among the residents who are expected to cover the extra work.11 If the cross-coverage plan for maternity leave is haphazard and only created as the need arises, fellow residents tend to feel that the burden of work is allocated capriciously. If allowed to persist, the resulting frustration damages the program’s collegiality and may result in a view of women as a risk to the best function of the department.6 This consequence damages both the departmental image and the status of women in medicine.

Proactive departmental planning for maternity leave and potentially reduced work hours for women with small children in residency training should be a priority and should be well defined prior to the employment of new residents. Any plan needs to include options, including a brief, fixed maternity leave and a more extended leave with obligations for time payback or flexible extension of the residency with reduced work hours per week. A leave plan must also include the number of weeks a resident can be absent in a year, in two years, and for the duration of the residency, while still fulfilling requirements for board eligibility. Likewise, to ensure a fundamental knowledge base, rotations that must be successfully completed should be clearly enumerated as part of the policy. As a corollary, paternity policy should also be specifically delineated.

Even residents who don’t utilize the flexible option residency like the idea that it is available if needed and believe that having a policy in place is desirable.7 Maintaining a positive espirit de corps in a residency training program is vital to the smooth functioning of the program and also mentors residents on the benefits of collegiality for a lifetime of practice. Developing a well-thought-out and equitable plan for maternity, health, or family leave during residency training is as essential as figuring out how to teach medicine to residents in an 80-hour week—and it can be done. TH

Dr. Brezina is a hospitalist at Durham Regional Medical Hospital in Durham, N.C., and a member of the consulting clinical faculty at Duke University, Durham, N.C.